Provider Demographics
NPI:1871661777
Name:C. KEITH GRISHAM, M.D. , P.A.
Entity Type:Organization
Organization Name:C. KEITH GRISHAM, M.D. , P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:C
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:GRISHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-781-1515
Mailing Address - Street 1:3108 MIDWAY RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-6383
Mailing Address - Country:US
Mailing Address - Phone:972-971-1515
Mailing Address - Fax:972-781-1313
Practice Address - Street 1:3108 MIDWAY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-6383
Practice Address - Country:US
Practice Address - Phone:972-971-1515
Practice Address - Fax:972-781-1313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9791207V00000X, 207VG0400X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Not Answered207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Not Answered207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH14708Medicare UPIN